Closing Care Gaps
Date: 12/14/20
Care Gap Questions
What are care gaps?
A care gap occurs when a required service/screening/monitoring/immunizations has not been completed. Examples of required services – Child: EPSDT Well Visit, Preventive Dental; Adult: Breast Cancer Screening, HbA1c testing.
Why is it important to close them?
To provide the best care to your patients.
To meet contract requirements and value-based purchasing agreements.
Where do I see my patient’s care gaps?
The provider portal that is currently used for eligibility, claims, and authorizations has been expanded to include a Provider Analytics tool. The Provider Analytics tool is a self-service option through the provider portal where provider can access their gap lists. The data is refreshed monthly. Instructions are on the attached PowerPoint (reference only). Any questions, please contact Amy Couch (amy.d.couch@azcompletehealth.com) or Kevin Lloy (Kevin.M.Lloyd@azcompletehealth.com).
Tips for Closing Care Gaps
1. Consider reviewing patients’ medical record proactively before the appointment and identify any potential care gaps with the Provider Analytics tool or review for the upcoming appointment. Perhaps this identification step can be added to your current eligibility check and scheduling processes.
2. Evaluate the identified care gaps. Can they all be completed in one appointment? If not, can the notes for follow up indicat what is still open so that it is on the radar for the next time the patient schedules an appointment. Better yet, schedule follow up appointment for the patient before they leave the office with an appointment in hand for those needed services.
3. Consider targeted campaigns and patient education to assist with patients owning and being proactive in their care. It benefits all of us to engage patients to become a partner in their care and health.
a. AzCH’s My Health Pays is a member incentive program you can include in your outreach.
4. Design outreach efforts around the actionable data, such as the care gaps pulled from the Provider Analytics tool.
a. Plan your outreach based on what will impact the majority of your population.
b. For example, if you have a large number of patients in the breast cancer screening measure listed, you can target that measure and impact a large number of patients. Check to see what programs AzCH is currently highlighting, such as opportunities to advise patients of mobile mammogram events.
5. Teach at every touchpoint, make recommendations, and remind of recommended screenings based on the patient. Remember you are the driving force for patients to receive their needed services.
6. In addition, care coordination and collaboration with other providers and specialists can keep the member engaged with their care.
7. Add more flexibility in your practice by increasing services in the home or via telemedicine. Additional opportunities are available, such as point of care testing (ex: HbA1c, urine protein)* or FIT kits for colorectal cancer screenings.
8. Be proactive with scheduling by prioritizing rescheduling when a patient cancels or no shows to ensure important screenings or monitoring appointments have been completed. During the rescheduling call, identify any barriers that are hindering the patient from attending, such as transportation.
9. If you are having trouble engaging the patient or the patient is high risk, reach out to AzCH Care Management via email (AZCHIntegratedCM@azcompletehealth.com). This team can help you with adults or children with complex conditions or frequent ED/hospitalizations. The Care Management team can also assist patients who are having difficulty managing the following chronic illnesses: diabetes, COPD, asthma, anxiety, or chronic pain/opioid use.
10. Increase use of CPT II codes, when appropriate, to reduce medical records requests, patient outreach, and your office workload.